question re: Picc line

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    i went to my patient's room to start iv and noticed that her picc line is pulled out about 3cm from her arm.. i aspirated back and i was able to get blood return. does it mean i can still use it or is it out of the position and i need another chest x-ray? what do you guys do in this situation?
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  3. 10 Comments so far...

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    I'd pull up the CXR and take a look at how far it is in the subclavian. It depends on how far it is from the brachial-- if there is any question in my mind, I would order a CXR. Especially if there are viscious meds going through.
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    I'm guessing you work in a hospital setting? I don't really have much advice for you, but I work in (and love) home infusion. We do weekly dressing changes on PICC lines, & we measure (& chart) the extension amount at each visit. We also measure & chart the circumference of the pt's arm weekly, because swelling in the arm could alert you to a problem with the line. We don't generally worry about how much is showing (unless it is a lot more than at the previous visit) as long as we can obtain a positive blood return. When was the PICC line placed on your pt? I'm thinking it was probably done with x-ray verification? When was the dressing changed last? Is the line sutured into the arm, or is a Statlock used instead? Typically, the line will come out a little with the dressing change, because of the stickiness of the Tegaderm when it is lifted. Sorry I can't really help you without knowing the answers to these questions...good luck to you & have a wonderful day! Hopefully someone else on here will be better able to provide you with the answers you are searching...
    Last edit by medicmama921 on Jun 29, '09 : Reason: misspelled word
    brownbook likes this.
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    where i work, you can still use a picc that has come out a bit because it essentially just becomes a regular IV line...it is migrating in we were taught that would be a problem.
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    If you want to make sure the line is still in a large central vein, you will need a chest xray. Looking at the previous xray and trying to figure it out is something I would only expect from an experienced ICU or PICC nurse. Best bet is always to call the doc when in doubt. As for those that said its okay as long as you get blood return, well that's inaccurate because blood return alone won't tell you if its in good position in a central vein.
    Up2nogood RN likes this.
  8. 1
    3 cm is our "magic number"........we need to reconfirm placement if either, the lower arm circumference increases 3 cm from baseline, or the external length increases 3 cm from baseline.

    So, yes, IMO, you need a CXR to check the line.
    brownbook likes this.
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    Its probably still fine, but you need a chest xray to verify if it is still far enough in to be a PICC or if it has been withdrawn enough to be considered a midline PICC. At least at my facility, you can't give TPN through a midline, so this is important to know. I'd just call the doctor or ask on the next rounds depending on the acuity of the patient and how often you use the line.
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    In order to answer this question you need some information first...you need to know the original amt left externally visible and if it has been pulled back by a PICC nurse you will need that new number.....so if you have 5 cm and now there is 8...you need to do something about it.........the average length of the Superior Vena Cava is 7 cm and optimal tip placement is in the lower third of the SVC......you will see this reported as low SVC or at the junction of the SVC and RA.....PICCs that are in the RA need to be pulled back by the PICC nurse.....so you need to know where the tip was right after it was placed and the amt externally visible....so you see if you are at the junction of the SVC and RA originally...you will be in the mid SVC after 3 cm more has been pulled out....BUT you will still need a CXR to make sure...please be aware that in certain patients for a variety of reasons you may not be able to get into the SVC.....and there is no other option....you can discuss this with the MD and get an order to use it....this is crucail as both the INS and NAVAN have position statements about optimal tip location...good documentation is very important in these situations...so please consult a PICC nurse in both of these instances ...lets just say you were in the upper SVC before it got pulled back 3 cm...now you will no longer be in the SVC...you will be in the brachiocephalic....so why is this a big deal (and by the way its not true that inward migratioin is all that matters..outward migration matters too!!!)Its a big deal because EVERY complication is increased the farther you get away from the low SVC...especially venous thrombosis...and if the patient has a complication and you deviated from the standard of care without a documented good reason and communication with the MD...basically they got ya.......the research studies show this and the position statements have held up in court....about 2 yrs ago a man won a 7 million dollare lawsuit b/c this hospital had placed 2 PICCs into the mis Subclavain and he got nerve damage in both arms...they thought this OK..they never even tried to advance thenm into the SVC....he had a problem with thrombosis with the first one...and then placed another just like it in the other arm...YIKES...someone did not know the standard of care......so there you go...call the PICC nurse..get a CXR and do not let any PICCs migrate out with dressing changes...it can be done as I do it every day...if it does get pulled out of the SVC and patient still needs it,,,,YOU need to replace it.....as you are putting the patient at increased risk for EVERY complication
    bsrn0523 likes this.
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    Nice description, iluvivt! yes indeed optimal placement is to have the tip in the lower 3rd of the svc, however it being pulled back 3 cm can still be in the svc, just not the lower third. Every pt's anatomy is different, and you'll need to verify the patient isn't receiving a vesicant or irritating drug; tpn can be written for peripheral concentrations. One more thing, just ask your IVT team what the protocol is for your institution, and again check with the md for need for cxr to verify placement.
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    Thanks!!! sure it probably still is in the SVC...probably mid...and if pt has a long SVC may even still be in the low..The SVC is good.......IV nutrition with 10% glucose or less would be PPN and yes you could give that in a peripheral vein...I still dislike it though b/c you have to re-start that IV practically every day...but its OK for an urgent need..then we get something better...Ok yes the vesicant/irritating drug thing can get confusing....so think about it this way...say you are giving Dopamine and your PICC get pulled out enough to be in the Subclavain vein and you confirmed that by CXR and the PICC team is gone......are you going to start a PIV b/c the drug is irritating.....NO...it is still better to give it in that large vessel......get an order to use it there...and then replace it ASAP.....remember you get much better hemodilution in those large vessels...there are really very few things YOU MUST give centrally....TPN and Continuous vesicant chemo...that is it.....NOW that is not to say that there are MANY MANY drugs that should be infused via a central access...such as Amio.....3 and 5 percent NS.....Dopamine and Dobutamine....but you do what you have to do at the time...and then get a better access ASAP...if you still need it...think not only delivering the drug and IVF..think vein preservation
    Last edit by iluvivt on Jun 29, '09


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